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Background: Neck pain is among the most prevalent and costly musculoskeletal disorders. Manual therapy and exercise are two standard treatment approaches to manage neck pain. In addition, clinical practice guidelines recommend a multi-modal approach, including both manual therapy and exercise for the treatment of neck pain; however, the specific effects of these combined interventions have not recently been reported in the literature. Objective: To perform a systematic review and meta-analysis to determine the effect of manual therapy combined with exercise on pain, disability, and quality of life in individuals with nonspecific neck pain. Design: Systematic Review and Meta-Analysis Methods: Electronic database searches were completed in PubMed, CINAHL, Cochrane, EMBASE, Ovid, and SportDiscus, with publication dates of January 2000 to December 2022. The risk of bias in the included articles was completed using the Revised Cochrane Risk of Bias Tool (RoB 2). Raw data were pooled using standardized mean differences and mean differences for pain, disability, and quality of life outcomes, and forest plots were computed in the metaanalysis. Results: Twenty-two studies were included in the final review. With moderate certainty of evidence, three studies demonstrated no significant difference between manual therapy plus exercise and manual therapy alone in pain (SMD of −0.25 (95% CI: −0.52, 0.02)) or disability (−0.37 (95% CI: −0.92, 0.18)). With a low certainty of evidence, 16 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing pain (−0.95 (95%CI: −1.38, −0.51)). Similarly, with low certainty of evidence, 13 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing disability (−0.59 (95% CI: −0.90, −0.28)). Four studies demonstrated that manual therapy plus exercise is significantly better than a control intervention for reducing pain (moderate certainty) (−2.15 (95%CI: −3.58, −0.73)) and disability (low certainty) (−2.39 (95% CI: −3.80, −0.98)). With a high certainty of evidence, four studies demonstrated no significant difference between manual therapy plus exercise and exercise alone in quality of life (SMD of −0.02 (95% CI: −0.21, 0.18)). Conclusion: Based on this systematic review and meta-analysis, a multi-modal treatment approach including exercise and manual therapy appears to provide similar effects as manual therapy alone, but is more effective than exercise alone or other interventions (control, placebo, ‘conventional physical therapy’, etc.) for the treatment of nonspecific neck pain and related disability. Some caution needs to be taken when interpreting these results given the general low to moderate certainty of the quality of the evidence. [ABSTRACT FROM AUTHOR]

Conservative management of lumbar radiculopathy (LR) is the first treatment option. To date, systematic reviews and clinical practice guidelines have not considered the most appropriate timing of management. This study aimed to establish consensus on effective conservative treatment modalities across different stages (i.e., acute, sub-acute, or chronic) of LR. Through an iterative multistage Delphi process, experts rated agreement with proposed treatment modalities across stages of LR and could suggest additional treatment modalities. The agreement was measured using a 5-point Likert scale. Descriptive statistics were used to measure agreement (median, interquartile ranges, and percentage of agreement). Consensus criteria were defined a priori for each round. Fourteen panelists produced a consensus list of effective treatment modalities across stages of LR. Acute stage management should focus on providing patients with information about the condition including pain education, individualized physical activity, and directional preference exercises, supported with NSAIDs. In the sub-acute stage, strength training and neurodynamic mobilization could be added and transforaminal/epidural injections considered. In the chronic stage, spinal manipulative therapy, specific exercise, and function-specific physical training should be combined with individualized vocational, ergonomic and postural advice. Experts agree effectiveness of interventions differs through the evolution of LR. To date clinical guideline for conservative management of lumbar radiculopathy do not consider the evolution of the condition. Acute stage management of lumbar radiculopathy should focus on providing information about the condition and support individualized physical activity with pain medication. Sub-acute management should add neurodynamic mobilization to strength training, while transforaminal and/or epidural injections could be considered. Chronic stage management should consider spinal manipulative therapy and focus on restoring personalized functional capacity. [ABSTRACT FROM AUTHOR]

Background Shoulder pain related to the long head of the biceps tendon (LHBT) tendinopathy can be debilitating and difficult to treat especially in athletes who often elect for surgical intervention. Conservative management is recommended but there are limited established guidelines on the physical therapy (PT) management of the condition. Hypothesis/Purpose The purpose of this study was to establish consensus on conservative, non-surgical physical therapy interventions for individuals with LHBT tendinopathy using the Delphi method approach. Study Design Delphi Study Methods Through an iterative process, experts in the PT field rated their agreement with a list of proposed treatment interventions and suggested additional interventions during each round. Agreement was measured using a four-point Likert scale. Descriptive statistics including median and percentage agreement were used to measure agreement. Data analysis at the end of Round III produced, by consensus, a list of PT interventions recommended for the management of individuals with LHBT tendinopathy. Consensus was defined as an a priori cutoff of ≥75% agreement. Results The respondent group included 29 international experts in the PT management of individuals with shoulder pain. At the conclusion of the study 61 interventions were designated as recommended based on consensus amongst experts and 9 interventions were not recommended based on the same criteria, 15 interventions did not achieve consensus. Conclusion There is a lack of well-defined, PT interventions used to treat LHBT tendinopathy. Expert respondents reached consensus on multimodal interventions including exercise, manual therapy and patient education to manage LHBT tendinopathy. Level of Evidence 5 [ABSTRACT FROM AUTHOR]

To determine if thoracic spine manipulation (TSM) improves pain and disability in individuals with cervicogenic headache (CeH). A randomized controlled crossover trial was conducted on 48 participants (mean age: 34.4 years) with CeH symptoms. Participants were randomized to 6 sessions of TSM or no treatment (Hold) and after 4-weeks, groups crossed over. Outcomes were collected at 4, 8 and 12 weeks and included: headache disability inventory (HDI), neck disability index (NDI), and the global rating of change (GRC). Outcomes were analyzed using a linear mixed-effects model with Bonferroni correction. Odds of achieving the minimal clinically important difference (MCID) on the GRC of +4 or greater were also calculated. Scores at 4 weeks represent the only timepoint where 1 group is fully treated and other group has not received any treatment. Comparing hold to active treatment, HDI were not significantly different between groups (mean difference = 7.39, 95 CI: −4.39 to 19.18; P = 0.214) at any timepoint; the NDI was significant (mean difference = 6.90, 95 CI: 0.05 to 13.75; P = 0.048) at 4 weeks. Odds of achieving the +4 MCID on the GRC (OR = 38.0, 95 CI: 6.6 to 220.0; p < 0.001) favored TSM at 4 weeks. TSM had no effect on headache-related disability but resulted in significant improvements in neck-related disability and participant reported perceived improvement. Future studies are needed to examine the long-term impact of TSM in this population. [ABSTRACT FROM AUTHOR]

Objective. The purpose of this study was to develop a data-driven Bayesian network approach to understand the potential multivariate pathways of the effect of manual physical therapy in women with carpal tunnel syndrome (CTS). Methods. Data from a randomized clinical trial (n=104) were analyzed comparing manual therapy including desensitization maneuvers of the central nervous system versus surgery in women with CTS. All variables included in the original trial were included in a Bayesian network to explore its multivariate relationship. The model was used to quantify the direct and indirect pathways of the effect of physical therapy and surgery on short-term,mid-term, and long-term changes in the clinical variables of pain, related function, and symptom severity. Results. Manual physical therapy improved function in women with CTS (between-groups difference: 0.09; 95% CI=0.07 to 0.11). The Bayesian network showed that early improvements (at 1 month) in function and symptom severity led to longterm (at 12 months) changes in related disability both directly and via complex pathways involving baseline pain intensity and depression levels. Additionally, women with moderate CTS had 0.14-point (95% CI=0.11 to 0.17 point) poorer function at 12 months than those with mild CTS and 0.12-point (95% CI=0.09 to 0.15 point) poorer function at 12 months than those with severe CTS. Conclusion. Current findings suggest that short-term benefits in function and symptom severity observed after manual therapy/surgery were associated with long-term improvements in function, but mechanisms driving these effects interact with depression levels and severity as assessed using electromyography. Nevertheless, it should be noted that betweengroup differences depending on severity determined using electromyography were small, and the clinical relevance is elusive. Further data-driven analyses involving a broad range of biopsychosocial variables are recommended to fully understand the pathways underpinning CTS treatment effects. Impact. Short-term effects of physical manual therapy seem to be clinically relevant for obtaining long-term effects in women with CTS. [ABSTRACT FROM AUTHOR]

* OBJECTIVES: To identify the most common type and timing of interventions used to initially manage patellofemoral pain (PFP), and whether exercise therapy as an initial treatment was associated with a decreased likelihood of recurrence of PFR. *DESIGN: Retrospective cohort. *METHODS: Active-duty military service members (n = 74408) aged 18 to 50 years and diagnosed with PFP between 2010 and 2011 were included. We identified the type and timing of interventions from electronic medical records and insurance payer claims, and studied the influence of early exercise therapy use on injury recurrence rates. * RESULTS: In this cohort of patients with PFR 62.3% (n = 46338) sought no additional care after the initial visit. The most common initial pharmacological interventions were nonsteroidal anti-inflammatory drugs (4.1%), corticosteroid injections (0.4%), and muscle relaxers (0.3%). The most common initial nonpharmacological treatments were exercise therapy (7.6%), passive modalities (eg, hot packs, electrical stimulation, ultrasound; 0.6%), and manual therapy (joint manipulation and mobilization; 0.5%). Common specialty referrals were to physical therapy (3.3%) and orthopaedic providers (0.8%). If patients received at least 6 exercise therapy visits during the initial episode of care, they were less likely to have a recurrence of knee pain (odds ratio = 0.46; 95% confidence interval: 0.42, 0.49). *CONCLUSION: Two in every 3 patients did not seek additional care after PFP diagnosis. For those who sought additional care, exercise therapy was the most common intervention, and higher doses of exercise therapy were associated with a reduced likelihood of having a recurrent episode of knee pain. [ABSTRACT FROM AUTHOR]

* OBJECTIVE: To examine the short- and long-term effectiveness of dry needling on disability, pain, and patient-perceived improvements in patients with mechanical neck pain when added to a multimodal treatment program that includes manual therapy and exercise. * DESIGN: Randomized controlled trial. * METHODS: Seventy-seven adults (mean + SD age, 46.68 ± 14.18 years: 79% female) who were referred to physical therapy with acute, subacute, or chronic mechanical neck pain were randomly allocated to receive 7 multimodal treatment sessions over 4 weeks of (1) dry needling, manual therapy, and exercise (needling group); or (2) sham dry needling, manual therapy, and exercise (sham needling group). The primary outcome of disability (Neck Disability Index score) and secondary outcomes of pain (current and 24-hour average) and patient-perceived improvement were assessed at baseline and follow-ups of 4 weeks, 6 months, and 1 year by blinded assessors. Between-group differences were analyzed with a 2-way, repeated-measures analysis of variance. Global rating of change was analyzed with a Mann-Whitney U test. * RESULTS: There were no group-by-time interac tions for disability (Ned( Disability Index: F2.37,177.47 = 0.42, P =.69), current pain (visual analog scale: F2. 84,213.16= 1.04, P - = .37), or average pain over 24 hours (F2,64.198.02 = 0.01, P = .10) There were no between-group differences for global rating of change at any time point (P≥.65). Both groups improved over time for all variables (Neck Disability Index: F2.37,177.47 = 124.70 P<.001; current pain: F2.84,213.16 = 64.28, P<.001, and average pain over 24 hours: F2.64,198.02 = 76.69, P<.001) CONCLUSION: There were no differences in outcomes between trigger point dry needling and sham dry needling when added to a multimodal treatment program for neck pain. Dry needling should not be part of a first-line approach to managing neck pain. [ABSTRACT FROM AUTHOR]

Objective No study to our knowledge has investigated the effects longer than 1 year of manual therapy in carpal tunnel syndrome (CTS). The purpose of this study was to investigate the effects of manual therapy versus surgery at 4-year follow-up and to compare the post-study surgery rate in CTS. Methods This randomized controlled trial was conducted in a tertiary public hospital and included 120 women with CTS who were randomly allocated to manual therapy or surgery. The participants received 3 sessions of physical therapy, including desensitization maneuvers of the central nervous system or carpal tunnel release combined with a tendon/nerve gliding exercise program at home. Primary outcome was pain intensity (mean and the worst pain). Secondary outcomes included functional status, symptom severity, and self-perceived improvement measured using a global rating of change scale. Outcomes for this analysis were assessed at baseline, 1 year, and 4 years. The rate of surgical intervention received by each group was assessed throughout the study. Results At 4 years, 97 (81%) women completed the study. Between-group changes for all outcomes were not significantly different at 1 year (mean pain: mean difference [MD] = −0.3, 95% CI = −0.9 to 0.3; worst pain: MD = −1.2, 95% CI = −3.6 to 1.2; function: MD = −0.1, 95% CI = −0.4 to 0.2; symptom severity: MD = −0.1, 95% CI = −0.3 to 0.1) and 4 years (mean pain: MD = 0.1, 95% CI = −0.2 to 0.4; worst pain: MD = 0.2, 95% CI = −0.8 to 1.2; function: MD = 0.1, 95% CI = −0.1 to 0.3; symptom severity: MD = 0.2, 95% CI = −0.2 to 0.6). Self-perceived improvement was also similar in both groups. No between-group differences (15% physical therapy vs 13% surgery) in surgery rate were observed during the 4 years. Conclusions In the long term, manual therapy, including desensitization maneuvers of the central nervous system, resulted in similar outcomes and similar surgery rates compared with surgery in women with CTS. Both interventions were combined with a tendon/nerve gliding exercise program at home. Impact This is the first study to our knowledge to report clinical outcomes and surgical rates during a 4-year follow-up and will inform decisions regarding surgical versus conservative management of CTS. Lay summary Women with CTS may receive similar benefit from a more conservative treatment—manual therapy—as they would from surgery. [ABSTRACT FROM AUTHOR]

To investigate the immediate changes in resting and contracted thickness of the transversus abdominis (TrA) muscle after application of thrust joint manipulation (TJM) vs sham manipulation in participants with low back pain. A pretest–posttest randomized controlled trial design was performed. Consecutive subjects satisfying eligibility criteria completed patient-report outcome baseline measures, pretreatment rehabilitative ultrasound imaging (RUSI) measurements, followed by the randomly assigned intervention then, post-treatment RUSI measurements, and post-treatment & final patient-reported outcome measures. To compare the outcomes of TJM and sham manipulation on the TrA muscle thickness, a 2-by-2 analysis of variance (treatment [TJM and sham manipulation]) by time (pretreatment and post-treatment) was completed for both the TrA muscle thickness at rest and muscle thickness during contraction. Descriptive statistics including independent-sample t tests for continuous variables and χ2 tests for categorical variables were used to analyze differences in patient-reported outcome measures between groups. Sixty-seven eligible participants agreed to participate. No significant interactions were identified for either muscle thickness at rest or contraction. This study did not support the hypothesis that manipulation would result in greater changes in TrA thickness at rest or during contraction in participants with low back pain. Based on prior research that identified subgroups of participants likely to respond to manipulation, future research should include participants more likely to respond favorably to TJM. This study was a priori registered with clinicaltrails.gov (NCT02558855). [ABSTRACT FROM AUTHOR]

Objective This randomized clinical trial investigated the effects of adding cervico-mandibular manual therapies into an exercise and educational program on clinical outcomes in individuals with tinnitus associated with temporomandibular disorders (TMDs). Methods Sixty-one patients with tinnitus attributed to TMD were randomized into the physiotherapy and manual therapy group or physiotherapy alone group. All patients received six sessions of physiotherapy treatment including cranio-cervical and temporomandibular joint (TMJ) exercises, self-massage, and patient education for a period of one month. Patients allocated to the manual therapy group also received cervico-mandibular manual therapies targeting the TMJ and cervical and masticatory muscles. Primary outcomes included TMD pain intensity and tinnitus severity. Secondary outcomes included tinnitus-related handicap (Tinnitus Handicap Inventory [THI]), TMD-related disability (Craniofacial Pain and Disability Inventory [CF-PDI]), self-rated quality of life (12-item Short Form Health Survey [SF-12]), depressive symptoms (Beck Depression Inventory [BDI-II]), pressure pain thresholds (PPTs), and mandibular range of motion. Patients were assessed at baseline, one week, three months, and six months after intervention by a blinded assessor. Results The adjusted analyses showed better outcomes (all, P  < 0.001) in the exercise/education plus manual therapy group (large effect sizes) for TMD pain (η 2 P = 0.153), tinnitus severity (η 2 P = 0.233), THI (η 2 P = 0.501), CF-PDI (η 2 P = 0.395), BDI-II (η 2 P = 0.194), PPTs (0.363 < η 2 P  < 0.415), and range of motion (η 2 P = 0.350), but similar changes for the SF-12 (P  = 0.622, η 2 P = 0.01) as the exercise/education alone group. Conclusions This clinical trial found that application of cervico-mandibular manual therapies in combination with exercise and education resulted in better outcomes than application of exercise/education alone in individuals with tinnitus attributed to TMD. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the short-term effectiveness of thoracic manipulation when compared to sham manipulation for individuals with low back pain (LBP). DESIGN: Randomized controlled trial. METHODS: Patients with LBP were stratified based on symptom duration and randomly assigned to a thoracic manipulation or sham manipulation treatment group. Groups received 3 visits that included manipulation or sham manipulation, core stabilization exercises, and patient education. Factorial repeated-measures analysis of variance and multiple regression were performed for pain, disability, and fear avoidance. The Mann-Whitney U test was used to analyze patient-perceived improvement, via the global rating of change scale, at follow-up. RESULTS: Ninety participants completed the study (mean + SD age, 38 ± 11.5 years; 70% female; 72% with chronic LBP). The overall group-by-time interaction was not significant for the Modified Oswestry Disability Questionnaire, numeric pain-rating scale, and Fear-Avoidance Beliefs Questionnaire outcomes. The global rating of change scale was not significantly different between groups. CONCLUSION: Three sessions of thoracic manipulation, education, and exercise did not result in improved outcomes when compared to a sham manipulation, education, and exercise in individuals with chronic LBP. Future studies are needed to identify the most effective management strategies for the treatment of LBP. [ABSTRACT FROM AUTHOR]

• Physical therapists routinely examine strength, range of motion and muscle flexibility of the hip(s) for individuals with low back pain. • Physical therapists often provide strengthening and flexibility interventions targeting the hips for individuals with low back pain. • Post-professional fellowship training as a physical therapist changed intervention selection to include more joint manual therapy and less muscle flexibility and modality usage. The main research aims were to investigate whether physical therapists are examining the hip(s) in individuals with a primary complaint of low back pain (LBP) and if so, the interventions being provided that target the hip(s). An anonymous electronic survey was distributed to the membership of the American Physical Therapy Association Orthopaedic and Sports Sections, as well as that of the American Academy of Orthopaedic Manual Physical Therapists. Participant demographics and survey responses were analyzed using descriptive statistics. Associations between variables were examined using chi-square analysis. The estimated response rate was 18.4% (n = 1163, mean age 40.5 ± 11.4 years). The majority of respondents (91%, n = 1059) reported they always or most of the time examined the hip(s) in individuals with LBP. The most common examination items utilized were hip strength testing (94%, n = 948), passive range of motion (91%, n = 921) and muscle flexibility testing (90%, n = 906). The most common interventions included hip strengthening (94%, n = 866) and hip flexibility exercises (90%, n = 814). Respondents enrolled in or having completed a post-professional fellowship were more likely to utilize hip joint manual therapy techniques (x 2 = 25.3, p = <0.001) and less likely to prescribe hip flexibility exercises (x 2 = 7.9, p = 0.005) or use electrophysical modalities (x 2 = 4.3, p = 0.039). Physical therapists commonly examine and provide interventions directed at the hip(s) for individuals with LBP. Post-professional fellowship training appears to influence the intervention selection of the physical therapist, with an increase in usage of hip joint manual therapy and a decrease in hip muscle flexibility and modality usage. [ABSTRACT FROM AUTHOR]

Background: Cervicogenic (CGH) and tension-type (TTH) headaches are prevalent conditions that are associated with considerable pain and disability. Joint mobilization and manipulation are common interventions used by physical therapists to manage individuals with musculoskeletal conditions. However, there is controversy surrounding their effectiveness. Objectives: To evaluate the effectiveness of mobilization and manipulation (MM) compared to other conservative treatments on reducing pain, frequency, and disability in patients with CGH and TTH. Methods: A literature search using terms related to mobilization, manipulation, CGH, and TTH was conducted to identify randomized clinical trials comparing MM to conservative treatment in treating CGH and TTH. The overall quality of the evidence was assessed using the Cochrane risk-of-bias tool. Meta-analysis and qualitative synthesis of the evidence were performed. Results: Nine total studies were included in the systematic review. The majority of studies scored lower than a 69% on the Cochrane risk of bias tool indicating a moderate to high risk of bias. MM were found to be equally as effective as conservative treatment in reducing pain, disability, and frequency of headache in individuals with CGH. MM had statistically significant short-term (1–4 weeks) improvements over conservative treatment for TTH on pain and disability, but not frequency. When comparing the effectiveness of MM versus conservative treatment for TTH, both groups exhibited improvement between 1–3 months in all three outcomes. Conclusions: Manipulation and mobilization were only found to be more effective than conservative care at short-term follow up for individuals with TTH. [ABSTRACT FROM AUTHOR]

* BACKGROUND: Carpal tunnel syndrome (CTS) results in substantial societal costs and can be treated either by nonsurgical or surgical approaches. * OBJECTIVE: To evaluate differences in cost-effectiveness of manual physical therapy versus surgery in women with CTS. * METHODS: In this randomized clinical trial, 120 women with a clinical and an electromyographic diagnosis of CTS were randomized through concealed allocation to either manual physical therapy or surgery. Interventions consisted of 3 sessions of manual physical therapy, including desensitization maneuvers of the central nervous system, or decompression/release of the carpal tunnel. Societal costs and health-related quality of life (estimated by the European Quality of Life-5 Dimensions [EQ-5D] scale) over 1 year were used to generate incremental cost per quality-adjusted life year ratios for each treatment. * RESULTS: The analysis was possible for 118 patients (98%). Incremental quality-adjusted life years showed greater cost-effectiveness in favor of manual physical therapy (difference, 0.135; 95% confidence interval: 0.134,0.136). Manual therapy was significantly less costly than surgery (mean difference in cost per patient, €2576; P<.001). Patients in the surgical group received a greater number of other treatments and made more visits to medical doctors than those receiving manual physical therapy (P = .02). Absenteeism from paid work was significantly higher in the surgery group (P<.001). The major contributors to societal costs were the treatment protocol (surgery versus manual therapy mean difference, €106980) and absenteeism from paid work (surgery versus manual physical therapy mean difference, €42224). * CONCLUSION: Manual physical therapy, including desensitization maneuvers of the central nervous system, has been found to be equally effective but less costly (ie, more cost-effective) than surgery for women with CTS. From a cost-benefit perspective, the proposed CTS manual physical therapy intervention can be considered. * LEVEL OF EVIDENCE: Economic and decision analyses, level 1b. [ABSTRACT FROM AUTHOR]

Abstract Objective The purpose of the current randomized clinical trial was to examine the effects of cervical thrust manipulation or sham manipulation on cervicocephalic kinaesthetic sense, pain, pain-related disability, and pressure pain sensitivity in patients with mechanical neck pain. Methods Fifty-four individuals with neck pain were randomly assigned to receive either a cervical manipulation (right or left) or a sham manipulation. Immediate outcomes included cervical kinesthetic sense as assessed by joint position sense error (JPSE) and pressure pain thresholds (PPTs). At 1 week, neck pain intensity (numerical pain rate scale) and neck pain-related disability (Neck Disability Index [NDI]) outcomes were also collected. Results The mixed-model analysis of covariance revealed a significant group × time interaction in favor of the cervical thrust manipulation group for the JPSE on rotation and extension. There was also a significant interaction for changes in PPTs at C5 to C6 and tibialis anterior. At the 1-week follow-up, a significant interaction existed for neck-related disability but not for neck pain at rest, worst pain, or lowest pain experienced the preceding week. Conclusions Our results suggest that cervical spine thrust manipulation improves JPSE, PPT and NDI in participants with chronic mechanical neck pain. Furthermore, changes in JPSE and NDI were large and surpass published minimal detectable changes for these outcome measures. In addition, the effect sizes of PPTs were medium; however, only C5 to C6 zygapophyseal joint exceeded the minimal detectable change. In contrast, cervical thrust manipulation did not improve neck pain intensity at 1 week after the intervention. [ABSTRACT FROM AUTHOR]

Abstract Objectives The purpose of this study was to identify descriptive factors in individuals with a primary complaint of low back pain (LBP) associated with improved pain and function after receiving physical therapy for LBP with or without manual therapy and exercise directed at the femoroacetabular joints. Methods Participants were enrolled in a randomized clinical trial investigating physical therapy interventions for their LBP, with or without interventions directed at the femoroacetabular joints (hips). A participant was deemed recovered if all of the following were met: Numeric Pain Rating Scale (NPRS) score of ≤2 points, ≤10% on the modified Oswestry Disability Index at discharge, and a global rating of change score of +4 at both 2 weeks and discharge. Logistic regression modelling determined descriptor variables that best predicted treatment recovery. Results Data from 90 participants were included in the analysis, with 44% (n = 40) achieving recovery by discharge from physical therapy (average 7.95 [±4.68]) visits. The variables of concurrent hip problems, lower body mass index ≤25.4, an irritable condition, and a baseline NPRS score of 4 points or less were retained in the final model (R2 =.384). Having a concurrent hip problem had the highest odds of achieving recovery in the model (odds ratio: 5.34, 95 % confidence interval: 1.31-21.8). Conclusions The findings for the patients in this study suggest that those with a concurrent hip problem, a lower body mass index, irritable symptoms, and a baseline NPRS score of 4 points or less were associated with greater odds of achieving recovery with multimodal physical therapy interventions. Further research should continue to investigate the interplay between the lumbar spine and hip joints. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Randomized clinical trial. BACKGROUND: The comparative effectiveness between nonthrust manipulation (NTM) and thrust manipulation (TM) for mechanical neck pain has been investigated, with inconsistent results. OBJECTIVE: To compare the clinical effectiveness of concordant cervical and thoracic NTM and TM for patients with mechanical neck pain. METHODS: The Neck Disability Index (NDI) was the primary outcome. Secondary outcomes included the Patient-Specific Functional Scale (PSFS), numeric pain-rating scale (NPRS), deep cervical flexion endurance (DCF), global rating of change (GROC), number of visits, and duration of care. The covariate was clinical equipoise for intervention. Outcomes were collected at baseline, visit 2, and discharge. Patients were randomly assigned to receive either NTM or TM directed at the cervical and thoracic spines. Techniques and dosages were selected pragmatically and applied to the most symptomatic level. Two-way mixed-model analyses of covariance were used to assess clinical outcomes at 3 time points. Analyses of covariance were used to assess between-group differences for the GROC, number of visits, and duration of care at discharge. RESULTS: One hundred three patients were included in the analyses (NTM, n = 55 and TM, n = 48). The between-group analyses revealed no differences in outcomes on the NDI (P = .67), PSFS (P = .26), NPRS (P = .25), DCF (P = .98), GROC (P = .77), number of visits (P = .21), and duration of care (P = .61) for patients with mechanical neck pain who received either NTM or TM. CONCLUSION: NTM and TM produce equivalent outcomes for patients with mechanical neck pain. The trial was registered with ClinicalTrials.gov (NCT02619500). LEVEL OF EVIDENCE: Therapy, level 1b. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to examine whether cerebral activation in response to noxious mechanical stimuli varies with thrust manipulation (TM) when compared with sham manipulation (SM) as measured by blood oxygenation level–dependent functional magnetic resonance imaging. Methods Twenty-four volunteers (67% female) with complaints of acute or subacute mechanical (nontraumatic) neck pain satisfied eligibility requirements and agreed to participate. Participants were randomized to receive TM to the thoracic spine or SM, and then underwent functional magnetic resonance scanning while receiving noxious stimuli before and after TM or SM. An 11-point numeric pain rating scale was administered pre- and postmanipulation for neck pain and to determine perceptions of pain intensity with respect to neck pain and mechanical stimuli. Blood oxygenation level–dependent functional magnetic resonance imaging recorded the cerebral hemodynamic response to the mechanical stimuli. Results Imaging revealed significant group differences, with those individuals in the manipulation group exhibiting increased areas of activation (postmanipulation) in the insular and somatosensory cortices and individuals in the sham group exhibiting greater areas of activation in the precentral gyrus, supplementary motor area, and cingulate cortices ( P < .05). However, between-group differences on the numeric pain rating scale for mechanical stimuli and for self-reported neck pain were not statistically significant. Conclusions This study provides preliminary level 2b evidence suggesting cortical responses in patients with nontraumatic neck pain may vary between thoracic TM and a sham comparator. [ABSTRACT FROM AUTHOR]

Background: No study has previously investigated the side, duration or number of audible cavitation sounds during high-velocity low-amplitude (HVLA) thrust manipulation to the cervicothoracic spine. Purpose: The primary purpose was to determine which side of the spine cavitates during cervicothoracic junction (CTJ) HVLA thrust manipulation. Secondary aims were to calculate the average number of cavitations, the duration of cervicothoracic thrust manipulation, and the duration of a single cavitation. Study Design: Quasi-experimental study Methods: Thirty-two patients with upper trapezius myalgia received two cervicothoracic HVLA thrust manipulations targeting the right and left T1-2 articulation, respectively. Two high sampling rate accelerometers were secured bilaterally 25 mm lateral to midline of the T1-2 interspace. For each manipulation, two audio signals were extracted using Short-Time Fourier Transformation (STFT) and singularly processed via spectrogram calculation in order to evaluate the frequency content and number of instantaneous energy bursts of both signals over time for each side of the CTJ. Result: Unilateral cavitation sounds were detected in 53 (91.4%) of 58 cervicothoracic HVLA thrust manipulations and bilateral cavitation sounds were detected in just five (8.6%) of the 58 thrust manipulations; that is, cavitation was significantly (p<0.001) more likely to occur unilaterally than bilaterally. In addition, cavitation was significantly (p<0.0001) more likely to occur on the side contralateral to the clinician's short-lever applicator. The mean number of audible cavitations per manipulation was 4.35 (95% CI 2.88, 5.76). The mean duration of a single manipulation was 60.77 ms (95% CI 28.25, 97.42) and the mean duration of a single audible cavitation was 4.13 ms (95% CI 0.82, 7.46). In addition to single-peak and multipeak energy bursts, spectrogram analysis also demonstrated high frequency sounds, low frequency sounds, and sounds of multiple frequencies for all 58 manipulations. Discussion: Cavitation was significantly more likely to occur unilaterally, and on the side contralateral to the short-lever applicator contact, during cervicothoracic HVLA thrust manipulation. Clinicians should expect multiple cavitation sounds when performing HVLA thrust manipulation to the CTJ. Due to the presence of multi-peak energy bursts and sounds of multiple frequencies, the cavitation hypothesis (i.e. intra-articular gas bubble collapse) alone appears unable to explain all of the audible sounds during HVLA thrust manipulation, and the possibility remains that several phenomena may be occurring simultaneously. Level of Evidence: 2b [ABSTRACT FROM AUTHOR]

* STUDY DESIGN: Randomized controlled trial. * BACKGROUND: Evidence suggests that multi-modal interventions that include exercise therapy may be effective for patellofemoral pain (PFP); however, no study has investigated the effects of trigger point (TrP) dry needling (DN) in people with PFP. * OBJECTIVES: To compare the effects of adding TrP DN to a manual therapy and exercise program on pain, function, and disability in individuals with PFP. * METHODS: Individuals with PFP (n = 60) recruited from a public hospital in Valencia, Spain were randomly allocated to manual therapy and exercises (n = 30) or manual therapy and exercise plus TrP DN (n = 30). Both groups received the same manual therapy and strengthening exercise program for 3 sessions (once a week for 3 weeks), and 1 group also received TrP DN to active TrPs within the vastus medialis and vastus lateralis muscles. The pain subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS; 0-100 scale) was used as the primary outcome. Secondary outcomes included other subscales of the KOOS, the Knee Society Score, the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), and the numeric pain-rating scale. Patients were assessed at baseline and at 15-day (posttreatment) and 3-month follow-ups. Analysis was conducted with mixed analyses of covariance, adjusted for baseline scores. * RESULTS: At 3 months, 58 subjects (97%) completed the follow-up. No significant between-group differences (all, P>.391) were observed for any outcome: KOOS pain subscale mean difference, -2.1 (95% confidence interval [Cl]: -4 .6,0 .4 ) ; IKDC mean difference, 2.3 (95% Cl: -0.1,4.7); knee pain intensity mean difference, 0.3 (95% Cl: -0.2, 0.8). Both groups experienced similar moderate-to-large within-group improvements in all outcomes (standardized mean differences of 0.6 to 1.1); however, only the KOOS function in sport and recreation subscale surpassed the prespecified minimum important change. * CONCLUSION: The current clinical trial suggests that the inclusion of 3 sessions of TrP DN in a manual therapy and exercise program did not result in improved outcomes for pain and disability in individuals with PFP at 3-month follow-up. * LEVEL OF EVIDENCE: Therapy, level 1b. Prospectively registered July 27,2015 at www. clinicaltrials.gov (NCT02514005). [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Secondary analysis of a randomized controlled trial. BACKGROUND: Prognostic variables identifying patients with shoulder pain who are likely to respond to cervicothoracic manipulation have been reported: however, they have yet to be validated. OBJECTIVE: To examine the validity of previously reported prognostic variables in predicting which patients with shoulder pain will respond to cervicothoracic manipulation. METHODS: Participants (n = 140) with a report of shoulder pain were randomly assigned to receive either 2 sessions of range-of-motion exercises plus 6 sessions o' stretching and strengthening exercises (exercise group), or 2 sessions of cervicothoracic manipulation and range-of-motion exercises followed by 6 sessions of stretching and strengthening exercise (manipulative-therapy-plus- exercise group). Outcomes of disability (Shoulder Pain and Disability Index, shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire) and pain (numeric pain-rating scale) were collected at baseline, 1 week, 4 weeks, and 6 months. Time, treatment group, status of predictor variables, and 2-way and 3-way interactions were analyzed using linear mixed models with repeated measures. RESULTS: There were no significant 3-way interactions for either disability (P = .27) or pain scores (P = .70) for time, group, and predictor status for any of the predictor variables. CONCLUSION: The results of the current study did not validate the previously identified prognostic variables; therefore, we cannot support using these in clinical practice. Further updating of the existing prediction rule may be warranted and could potentially result in new prognostic variables and improved generalizability. Limitations of the study were a mean duration of symptoms of greater than 2 years and a loss to follow-up of 19% at 6 months. LEVEL OF EVIDENCE: Prognosis, level lb. Trial prospectively registered March 30,2012 at www. clinicaltrials.gov (NCT01571674). [ABSTRACT FROM AUTHOR]

* STUDY DESIGN: Randomized parallel-group trial. * BACKGROUND: Carpal tunnel syndrome (CTS) is a common pain condition that can be managed surgically or conservatively. * OBJECTIVE: To compare the effectiveness of manual therapy versus surgery for improving self-reported function, cervical range of motion, and pinch-tip grip force in women with CTS. * METHODS: In this randomized clinical trial, 100 women with CTS were randomly allocated to either a manual therapy (n = 50) or a surgery (n = 50) group. The primary outcome was self-rated hand function, assessed with the Boston Carpal Tunnel Questionnaire. Secondary outcomes included active cervical range of motion, pinch-tip grip force, and the symptom severity subscale of the Boston Carpal Tunnel Questionnaire. Patients were assessed at baseline and 1,3,6, and 12 months after the last treatment by an assessor unaware of group assignment. Analysis was by intention to treat, with mixed analyses of covariance adjusted for baseline scores. * RESULTS: At 12 months, 94 women completed the follow-up. Analyses showed statistically significant differences in flavor of manual therapy at 1 month for self-reported function (mean change, -0.8; 95% confidence interval [Cl]: -1.1, -0.5) and pinch-tip grip force on the symptomatic side (thumb-index finger: mean change, 2,0; 95% CI: 1.1,2.9 and thumb-little finger: mean change, 1.0; 95% CI: 0.5,1.5). Improvements in self-reported function and pinch grip force were similar between the groups at 3, 6, and 12 months. Both groups reported improvements in symptom severity that were not significantly different at all follow-up periods. No significant changes were observed in pinch-tip grip force on the less symptomatic side and in cervical range of motion in either group. * CONCLUSION: Manual therapy and surgery had similar effectiveness for improving self-reported function, symptom severity, and pinch-tip grip force on the symptomatic hand in women with CTS. Neither manual therapy nor surgery resulted in changes in cervical range of motion. [ABSTRACT FROM AUTHOR]

* STUDY DESIGN: Multicenter randomized controlled trial. * BACKGROUND: Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. * OBJECTIVES: To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. * METHODS: Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. * RESULTS: There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). * CONCLUSION: Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. * LEVEL OF EVIDENCE: Therapy, level 1b. Prospectively registered March 30, 2012 at www. ClinicalTrials.gov (NCT01571674). [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Secondary analysis of a randomized trial. BACKGROUND: A clinical prediction rule to identify patients with carpal tunnel syndrome (CTS) most likely to respond to manual physical therapy has been published but requires further testing to determine its validity. OBJECTIVE: To assess the validity of a clinical prediction rule proposed for the management of patients with CTS in a different group of patients with a variety of treating clinicians. METHODS: A preplanned secondary analysis of a randomized controlled trial investigating the efficacy of manual physical therapies, including desensitization maneuvers of the central nervous system, in 120 women suffering from CTS was performed. Patients were randomized to receive 3 sessions of manual physical therapy (n = 60) or surgical release/decompression of the carpal tunnel (n = 60). Self-perceived improvement with a global rating of change was recorded at 6- and 12-month follow-ups. Pain intensity (mean pain and worst pain on a 0-to-10 numeric pain-rating scale) and scores on the Boston Carpal Tunnel Questionnaire (functional status and symptom severity subscales) were assessed at baseline and at 1,3, 6, and 12 months. A baseline assessment of status on the clinical prediction rule was performed (positive status on the clinical prediction rule was defined as meeting at least 2 of the following criteria: pressure pain threshold of less than 137 kPa over the affected C5-6 joint; heat pain threshold of less than 39.6°C over the affected carpal tunnel; and general health score [Medical Outcomes Study 36-Item Short-Form Health Survey] of greater than 66 points). Linear mixed models with repeated measures were used to examine the validity of the rule. RESULTS: Participants with a positive status on the rule who received manual physical therapy did not experience greater improvements compared to those with a negative status on the rule for mean pain (P = .65), worst pain (P = .86), function (P = .99), or symptom severity (P = .85). Further, the clinical prediction rule performed no better than chance in identifying the individuals with CTS most likely to respond to manual physical therapy or surgery (mean pain, P = .87; worst pain, P = .91; function, P = .60; severity, P = .66). No differences in self-perceived improvement were observed at either 6 (P = .68) or 12 (P = .36) months, according to the rule. CONCLUSION: The results of this study did not support the validity of the previously developed clinical prediction rule for manual physical therapy in women with CTS. [ABSTRACT FROM AUTHOR]

Background: Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH.Methods: One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable.Results: The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001).Conclusions: Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months.Trial Registration: NCT01580280 April 16, 2012. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to compare the immediate effects of mobilization with movement (MWM) to a sham technique in patients with shoulder impingement syndrome. Methods: A randomized controlled trial was performed. Forty-two patients (mean ± SD age, 55 ± 9 years; 81% female) satisfied eligibility criteria, agreed to participate, and were randomized into an MWM group (n = 21 ) or sham manual contact (n = 21 ). The primary outcome measures including pain intensity, pain during active range of motion, and maximal active range of motion were assessed by a clinician blinded to group allocation. Outcomes were captured at baseline and after 2 weeks of MWM treatment or sham intervention. The primary analysis was the group x time interaction. Results: The 2 x 2 analysis of variance revealed a significant group x time interaction for pain intensity during shoulder flexion (F = 7.054; P = .011), pain-free shoulder flexion (F = 32.853; P < .001), maximum shoulder flexion (F= 18.791; P < .01), and shoulder external rotation (F = 7.950; P < .01) in favor of the MWM group. No other significant differences were found. Conclusions: Patients with shoulder impingement syndrome who received 4 sessions of MWM exhibited significantly better outcomes for pain during shoulder flexion, pain-free range of shoulder flexion, maximal shoulder flexion, and maximal external rotation than those patients who were in the sham group. [ABSTRACT FROM AUTHOR]

STUDY DESIGN; Randomized clinical study. OBJECTIVES: To compare the effects of trigger point (TrP) dry needling (DN) and TrP manual therapy (MT) on pain, function, pressure pain sensitivity, and cervical range of motion in subjects with chronic mechanical neck pain. BACKGROUND: Recent evidence suggests that TrP DN could be effective in the treatment of neck pain. However, no studies have directly compared the outcomes of TrP DN and TrP MT in this population. METHODS: Ninety-four patients (mean ± SD age, 31 ± 3 years; 66% female) were randomized into a TrP DN group (n = 47) or a TrP MT group (n = 47). Neck pain intensity (11-point numeric pain rating scale), cervical range of motion, and pressure pain thresholds (PPTs) over the spinous process of C7 were measured at baseline, postintervention, and at follow-ups of 1 week and 2 weeks after treatment. The Spanish version of the Northwick Park Neck Pain Questionnaire was used to measure disability/function at baseline and the 2-week follow-up. Mixed-model, repeated-measures analyses of variance (ANOVAs) were used to determine if a time-by-group interaction existed on the effects of the treatment on each outcome variable, with time as the within-subject variable and group as the between-subject variable. RESULTS: The ANOVA revealed that participants who received TrP DN had outcomes similar to those who received TrP MT in terms of pain, function, and cervical range of motion. The 4-by-2 mixed-model ANOVA also revealed a significant time-by-group interaction (P<.001) for PPT: patients who received TrP DN experienced a greater increase in PPT (decreased pressure sensitivity) than those who received TrP MT at all follow-up periods (between-group differences: posttreatment, 59.0 kPa; 95% confidence interval [Cl]: 40.0, 69.2; 1- week follow-up, 69.2 kPa; 95% Cl: 49.5, 79.1; 2- week follow-up, 78.9 kPa; 95% Cl: 49.5, 89.0). CONCLUSION: The results of this clinical trial suggest that 2 sessions of TrP DN and TrP MT resulted in similar outcomes in terms of pain, disability, and cervical range of motion. Those in the TrP DN group experienced greater improvements in PPT over the cervical spine. Future trials are needed to examine the effects of TrP DN and TrP MT over long-term follow-up periods, [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The objectives of this study were (1) to examine patients' general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain, and (2) to assess the extent to which the patients' general and specific expectations for treatment, particularly spinal manipulation, affect clinical outcomes. BACKGROUND: Patient expectations can have a profound influence on the magnitude of treatment outcome across a broad variety of patient conditions. METHODS: We performed a secondary analysis of data from a clinical trial of interventions for neck pain. Prior to beginning treatment for neck pain, 140 patients were asked about their general expectations of benefit as well as their specific expectations for individual interventions. Next, we examined how these expectations related to the patients' ratings of the success of treatment at 1 and 6 months after treatment. RESULTS: Patients had positive expectations for treatment by a physical therapist, with more than 80% of patients expecting moderate relief of symptoms, prevention of disability, the ability to do more activity, and to sleep better. The manual therapy interventions of massage (87%) and manipulation (75%) had the highest proportion of patients who expected these interventions to significantly improve neck pain. These were followed by strengthening (70%) and range-of- motion (54%) exercises. Very few patients thought surgery would improve their neck pain (less than 1%). At 1 month, patients who were unsure of experiencing complete pain relief had lower odds of reporting a successful outcome than patients expecting complete relief (odds ratio [OR] = 0.33; 95% confidence interval [Cl]: 0.11, 0.99). Believing that manipulation would help and not receiving manipulation lowered the odds of success (OR = 0.16; 95% Cl: 0.04, 0.72) compared to believing manipulation would help and receiving manipulation. Six months after treatment, having unsure expectations for complete pain relief lowered the odds of success (OR = 0.19; 95% Cl: 0.05,0.7), whereas definitely expecting to do more exercise increased the odds of success (OR = 11.4; 95%: Cl: 1.7, 74.7). Regarding self-reported disability assessed with the Neck Disability Index, patients who believed manipulation would help and received manipulation reported less disability than those who did not believe manipulation would help and both received manipulation (mean difference, -3.8; 95% Cl: -5.9, -1.5; P = .006) and did not receive manipulation (mean difference, -5.7; 95% Cl; -9.3, -2.1; P = .014). There was also an interaction between time and the expectation for complete relief. CONCLUSION: General expectations of benefit have a strong influence on clinical outcomes for , patients with neck pain. LEVEL OF EVIDENCE: Prognosis, level 2b-. J Orthop Sports Phys Ther 2013;43(7):457-465. Epub 18 March 2013. doi:10.2519/jospt.2013.4492 s KEY WORDS: cervical spine, physical therapy techniques, treatment [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of manual therapy and exercise (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain. BACKGROUND: An in-clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared an MTEX approach to an HEP. METHODS: Patients with an inversion ankle sprain completed the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, the FAAM sports subscale, the Lower Extremity Functional Scale, and the numeric pain rating scale. Patients were randomly assigned to either an MTEX or an HEP treatment group. Outcomes were collected at baseline, 4 weeks, and 6 months. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance. The hypothesis of interest was the 2-way interaction (group by time). RESULTS: Seventy-four patients (mean ± SD age, 35.1 ± 11.0 years; 48.6% female) were randomized into the MTEX group (n = 37) or the HEP group (n = 37). The overall group-by-time interaction for the mixed-model analysis of variance was statistically significant for the FAAM activities of daily living subscale (P<.001), FAAM sports subscale (P<.001), Lower Extremity Functional Scale (P<.001), and pain (P≤001). Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group. CONCLUSION: The results suggest that an MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Registered at clinicaltrials.gov (NCT00797368). LEVEL OF EVIDENCE: Therapy, level lb- J Orthop Sports Phys Ther 2013;43(7):443-455: Epub 29 April 2013. doi:10.2519/jospt.2013.4792 [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Planned secondary analysis o a randomized controlled trial comparing neural tissue management (NTM) to advice to remain active. OBJECTIVE: To develop a model that predicts the likelihood of patient-reported improvement following NTM. BACKGROUND: Matching patients to an intervention they are likely to benefit from potentially improves outcomes. However, baseline characteristics that predict patients' responses to NTM are unknown. METHODS: Data came from 60 consecutive adults who had nontraumatic, nerve-related neck and unilateral arm pain for at least 4 weeks. Participants were assigned to a group that received NTM (n = 40), which involved brief education, manual therapy, and nerve gliding exercises for 4 treatments over 2 weeks, or to a group that was given advice to remain active (n = 20), which involved instruction to continue their usual activities. The participants' global rating of change at a 3-to 4-week follow-up defined improvement. Penalized regression of NTM data identified the best prediction model. A medical nomogram was created for prediction model scoring. Post hoc analysis determined whether the model predicted a specific response to NTM. RESULTS: Absence of neuropathic pain qualities, older age, and smaller deficits in median nerve neurodynamic test range of motion predicted improvement. Prediction model cutoffs increased the likelihood of improvement from 53% to 90% (95% confidence interval: 56%, 98%) or decreased the likelihood of improvement to 9% (95% confidence interval: 1%, 42%). The model did not predict the outcomes of the advice to remain active group. CONCLUSION: Baseline characteristics of patients with nerve-related neck and arm pain predicted the likelihood of improvement with NTM. Model performance needs to be validated in a new sample using different comparison interventions and longer follow-up. Australian New Zealand Clinical Trials Registry (ACTRN 12610000446066). [ABSTRACT FROM AUTHOR]

Abstract: Objective: The purpose of this study was to investigate changes in pressure sensitivity and pinch grip force in the nonsymptomatic side in patients with thumb carpometacarpal (CMC) osteoarthritis (OA) after the application of a unilateral passive accessory mobilization to the symptomatic hand. Methods: Secondary analysis of data from a randomized trial with concealed allocation, blinded assessor, and intention-to-treat analysis was performed. Twenty-eight patients (72% females), with unilateral CMC OA and mean age ± SD of 82 ± 6 years, met all the inclusion criteria and agreed to participate. The experimental group received passive accessory mobilization to the CMC OA, and the control group received a nontherapeutic dose of intermittent ultrasound on the affected side for 4 sessions over 2 weeks. Outcome measures including pressure pain thresholds (PPTs) at the lateral epicondyle, thumb CMC joint, tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone and tip and tripod pinch and grip strength of the contralateral/unaffected hand were assessed at baseline as well as 1 and 2 weeks after treatment by an assessor blinded to the group allocation. A repeated measures analysis of variance was used to determine changes in PPT and pinch and grip strength. Results: No important baseline differences were observed between groups. At the end of the follow-up period, the experimental group exhibited a significant increase in PPT at the CMC joint as compared with the control group 0.6 kg/cm2 (95% confidence interval, 0.3-1.0; F3.0 = 4.89; P = .009). Although PPT changes in the experimental group were higher than the control group at the remaining sites, differences did not reach statistically significance. Similarly, tip, tripod pinch, and grip strength remained unchanged after the intervention. Conclusion: This secondary analysis found that the application of a unilateral passive accessory mobilization targeted to the symptomatic CMC joint induced an increase of PPT levels 2 weeks after treatment; however, differences were small and likely of limited clinical value. No contralateral motor effects were observed. Future studies including larger sample sizes are needed to examine the effects of joint mobilization on motor and sensory effects. [Copyright &y& Elsevier]

STUDY DESIGN: Case series. OBJECTIVES: To use blood oxygenation level-dependent functional magnetic resonance imaging (fMRI) to determine if supraspinal activation in response to noxious mechanical stimuli varies pre- and post-thrust manipulation to the thoracic spine. BACKGROUND: Recent studies have demonstrated the effectiveness of thoracic thrust manipulation in reducing pain and improving function in some individuals with neck and shoulder pain. However, the mechanisms by which manipulation exerts such effects remain largely unexplained. The use of fMRI in the animal model has revealed a decrease in cortical activity in response to noxious stimuli following manual joint mobilization. Supraspinal mediation contributing to hypoalgesia in humans may be triggered following spinal manipulation. METHODS: Ten healthy volunteers (5 women, 5 men) between the ages of 23 and 48 years (mean, 31.2 years) were recruited. Subjects underwent fMRI scanning while receiving noxious stimuli applied to the cuticle of the index finger at a rate of 1 Hz for periods of 15 seconds, alternating with periods of 15 seconds without stimuli, for a total duration of 5 minutes. Subjects then received a supine thrust manipulation directed to the mid- thoracic spine and were immediately returned to the scanner for reimaging with a second delivery of noxious stimuli. An 11-point numeric pain rating scale was administered immediately after the application of noxious stimuli, premanipulation and postmanipulation. Blood oxygenation level-dependent fMRI recorded the cerebral hemodynamic response to the painful stimuli premanipulation and postmanipulation. RESULTS: The data indicated a significant reduction in subjects' perception of pain (P<.01), as well as a reduction in cerebral blood flow as measured by the blood oxygenation level-dependent response following manipulation to areas associated with the pain matrix (P<.05). There was a significant relationship between reduced activation in the insular cortex and decreased subjective pain ratings on the numeric pain rating scale (r = 0.59, P<.05). 8 CONCLUSION: This study provides preliminary evidence that suggests that supraspinal mechanisms may be associated with thoracic thrust manipulation and hypoalgesia. However, because the study lacked a control group, the results do not allow for the discernment of the causative effects of manipulation, which may also be related to changes in levels of subjects' fear, anxiety, or expectation of successful outcomes with manipulation. Future investigations should strive to elicit more conclusive findings in the form of randomized clinical trials. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Randomized clinical trial. To compare the effects of thrust and nonthrust manipulation and exercises with and without the addition of myofascial therapy for the treatment of acute inversion ankle sprain. BACKGROUND: Studies have reported that thrust and nonthrust manipulations of the ankle joint are effective for the management of patients post-ankle sprain. However, it is not known whether the inclusion of soft tissue myofascial therapy could further improve clinical and functional outcomes. METHODS: Fifty patients (37 men and 13 women; mean ± SD age, 33 ± 10 years) post-acute inversion ankle sprain were randomly assigned to 2 groups: a comparison group that received a thrust and nonthrust manipulation and exercise intervention, and an experimental group that received the same protocol and myofascial therapy. The primary outcomes were ankle pain at rest and functional ability. Additionally, ankle mobility and pressure pain threshold over the ankle were assessed by a clinician who was blinded to the treatment allocation. Outcomes of interest were captured at baseline, immediately after the treatment period, and at a 1-month follow-up. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model analyses of variance revealed a significant group-by-time interaction for ankle pain (P<.001) and functional score (P = .002), with the patients who received the combination of nonthrust and thrust manipulation and myofascial intervention experiencing a greater improvement in pain and function than those who received the nonthrust and thrust manipulation intervention alone. Significant group-by-time interactions were also observed for ankle mobility (P<.001) and pressure pain thresholds (all, P<.01), with those in the experimental group experiencing greater increases in ankle mobility and pressure pain thresholds. Between-group effect sizes were large (d>0.85) for all outcomes. CONCLUSION: This study provides evidence that, in the treatment of individuals post-inversion ankle sprain, the addition of myofascial therapy to a plan of care consisting of thrust and nonthrust manipulation and exercise may further improve outcomes compared to a plan of care solely consisting of thrust and nonthrust manipulation and exercise. However, though statistically significant, the difference in improvement in the primary outcome between groups was not greater than what would be considered a minimal clinically important difference. Future studies should examine the long-term effects of these interventions in this population. LEVEL OF EVIDENCE: Therapy, level lb- [ABSTRACT FROM AUTHOR]

Background: Thrust manipulation to the spine has been shown to be an effective treatment for pain reduction associated with musculoskeletal disorders. However, the mechanisms of action tied to this intervention have yet to be sufficiently explained. Objectives: This manuscript reviews the literature related to supraspinal mechanisms associated with pain inhibition, which may also be associated with hypoalgesia following spinal manipulation. Such information adds to the current body of evidence that has demonstrated centrally mediated hypoalgesic effects following manipulation to be influenced by both dorsal horn inhibition and patient expectation. Major findings: Areas believed to be responsible for processing pain include the amygdala, anterior cingulate, thalamus, insula, cerebellum, primary and secondary somatosensory cortices, periaqueductal grey, or dorsal horn. The periaqueductal grey receives information from spinoreticular and spinomesencephalic pathways in the spinal cord, as well as descending information from the amygdala and cortex. The inhibition of sensory stimuli in the dorsal horn may result in decreased projection of ascending information to the periaqueductal grey and modulation from higher-level cortical structures. Neuroimaging research in animals has demonstrated activation of such cortical structures in response to pain with subsequent decreased activation of these areas following joint mobilization. Researchers have yet to identify supraspinal structures associated with spinal manipulation in human subjects. Conclusions: Future investigation should strive to identify supraspinal structures activated in human subjects following thrust manipulation. The identification of cortical and subcortical structures associated with hypoalgesia following spinal manipulation may influence the acceptance and use of this intervention with patients when indicated. [ABSTRACT FROM AUTHOR]

The article reports a study to examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA). A double blind randomized control trial was conducted and data were analyzed using Statistical Product and Service Solutions (SPSS) version 18.0. This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain.

The article discusses a randomized control trial to find the short-term effects of thoracic spine thrust manipulation combined with cervical spine nonthrust manipulation versus cervical spine nonthrust manipulation (SNM) alone in individuals with mechanical neck pain. It states that both groups received the treatment sessions cervical SNM and a home exercise program. It is concluded that combination of cervical SNM and thoracic spine thrust manipulation and exercise is beneficial.

Abstract: Objective: The purpose of this prospective case series was to describe the outcomes of a set of rock climbers with lateral epicondylalgia (LE) treated with manual therapy directed at the cervical spine, elbow, and wrist as well as trigger point (TrP) dry needling and kinesio tape. Methods: Nine consecutive rock climbers presenting to physical therapy with a diagnosis of LE were included. At baseline, all patients completed the Patient-Rated Tennis Elbow Evaluation and underwent pain pressure threshold testing over the extensor carpi radialis, extensor carpi brevis, brachioradialis, and supinator muscles at baseline, after the third visit (week 3), and at 2-month follow-up. Treatment included manipulation of the cervical spine, mobilization with movement directed at the elbow, manipulation of the wrist, TrP dry needling, and kinesio tape. Results: Of the 9 subjects who participated in this study, 3 were women (33%), and the mean duration of symptoms was 3 weeks, with an SD of 1.7 weeks (median, 2 weeks; range, 1-6 weeks). There was an improvement in all outcome measures at both the final visit and 2-month follow-up period. Conclusions: This group of rock climbers with LE who were conservatively managed with a treatment approach consisting of cervical spine manipulation, mobilization directed at the elbow and wrist, and TrP dry needling as well as kinesio tape exhibited clinical improvement. [Copyright &y& Elsevier]

A reprint of the article "Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association" which appeared in the "Journal of Orthopaedic & Sports Physical Therapy" is presented. It discusses guidelines for the diagnosis, risk factors and interventions for neck pain. Some of interventions are cervical and thoracic mobilization, stretching exercises and traction.

Background. A clinical prediction rule (CPR) purported to identify patients with neck pain who are likely to respond to thoracic spine thrust manipulation has recently been developed, but has yet to be validated. Objective. The purpose of this study was to examine the validity of this CPR. Design. This was a multi-center randomized clinical trial. Methods. One hundred forty patients with a primary report of neck pain were randomly assigned to receive either 5 sessions of stretching and strengthening exercise (exercise-only group) or 2 sessions of thoracic spine manipulation and cervical range of motion exercise followed by 3 sessions of stretching and strengthening exercise (manipulation + exercise group). Data on disability and pain were collected at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group X time X status on the prediction rule) was examined using a linear mixed model with repeated measures. Time, treatment group, and status on the rule, as well as all possible 2-way and 3-way interactions, were modeled as fixed effects, with disability (and pain) as the dependent variable. Effect sizes were calculated for both pain and disability at each follow-up period. Results. There was no 3-way interaction for either disability or pain. A 2-way (group X time) interaction existed for both disability and pain. Pair-wise comparisons of disability demonstrated that significant differences existed at each follow-up period between the manipulation + exercise group and the exercise-only group. The patients who received manipulation exhibited lower pain scores at the 1-week follow-up period. The effect sizes were moderate for disability at each follow-up period and were moderate for pain at the 1-week follow-up. Limitations. Different exercise approaches may have resulted in a different outcome. Conclusions. The results of the current study did not support the validity of the previously developed (-PR. However, the results demonstrated that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and long- term follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background. It has been reported that manipulative therapy directed at the cervical and thoracic spine may improve outcomes in patients with shoulder pain. To date, limited data are available to help physical therapists determine which patients with shoulder pain may experience changes in pain and disability following the application of these interventions. Objective. The purpose of this study was to identify prognostic factors from the history and physical examination in individuals with shoulder pain who are likely to experience rapid improvement in pain and disability following cervical and thoracic spine manipulation. Design. This was a prospective single-arm trial. Setting. This study was conducted in outpatient physical therapy clinics. Participants. The participants were individuals who were seen by physical therapists for a primary complaint of shoulder pain. Intervention and Measurements. Participants underwent a standardized examination and then a series of thrust and nonthrust manipulations directed toward the cervicothoracic spine. Individuals were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. Results. Data for 80 individuals were included in the data analysis, of which 49 had a successful outcome. Five prognostic variables were retained in the final regression model. If 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89% (positive likelihood ratio=5.3). Limitations. A prospective single-arm trial lacking a control group does not allow for inferences to be made regarding cause and effect. The statistical procedures used may result in "overfitting" of the model, which can result in low precision of the prediction accuracy, and the bivariate analysis may have resulted in the rejection of some important variables. Conclusions. The identified prognostic variables will allow clinicians to make an a priori identification of individuals with shoulder pain who are likely to experience short-term improvement with cervical and thoracic spine manipulation. Future studies are necessary to validate these findings. [ABSTRACT FROM AUTHOR]

The article presents a randomized clinical trial which analyzes the generalizability of three different physical therapy techniques that is in accordance with a clinical prediction rule (CPR) among patient with low back pain (LBP). It explores the generalizability of the spinal manipulation CPR to various manipulation techniques based from the outcomes of three techniques in patients with LBP. Results show the generalizability of CPR in different settings from which it was derived and validated.

Objective: This study examines if C7-T1 manipulation results in changes in pressure pain thresholds (PPT) over bilateral C5-C6 zygapophyseal joints in asymptomatic subjects. Methods: Thirty subjects, 13 men and 17 women, without a current history of neck, shoulder, or upper extremity pain participated. Participants were randomly divided into 3 groups: experimental dominant group, subjects who received the manipulative thrust directed at the right side of the C7-T1 joint; experimental nondominant group, those who received the thrust on the left side of the C7-T1 joint; and a placebo group, those who received a sham-manual procedure. The outcome measure was the PPT on both right and left C5-C5 zygapophyseal joints, which was assessed at preintervention and 5 minutes postintervention by an assessor blinded to the treatment allocation of the subject. A 3-way repeated measures analysis of covariance was used to evaluate changes in PPT. Results: The analysis of covariance revealed time x group (F = 32.3; P < .001), time x side (F = 4.9; P < .05), time x sex (F = 7.93; P < .01), and time x group x sex (F = 7.606; P < .001) interactions. Post hoc analyses found that (a) both experimental groups showed greater improvements in PPT than the placebo group (P < .05), without significant differences between them (P > .6); (b) the right side had greater increases in PPT in both experimental groups (P < .05), but not within the placebo group (P > .8); (c) men experienced greater increases in PPT levels than women, particularly in the experimental nondominant group (P < .01). Within-group effect sizes were large for both experimental groups (d > 1), but small for the placebo condition (d < 0.2). Conclusions: These results suggest that a C7-T1 manipulation induced changes in PPT in both right and left C5-C6 zygapophyseal joints in healthy subjects. [ABSTRACT FROM AUTHOR]

Background and Purpose Evidence supports the use of manual physical therapy interventions directed at the thoracic spine in patients with neck pain. The purpose of this study was to compare the effectiveness of thoracic spine thrust mobilization/manipulation with that of nonthrust mobilization/manipulation in patients with a primary complaint of mechanical neck pain. The authors also sought to compare the frequencies, durations, and types of side effects between the groups. Subjects The subjects in this study were 60 patients who were 18 to 60 years of age and had a primary complaint of neck pain. Methods For all subjects, a standardized history and a physical examination were obtained. Self-report outcome measures included the Neck Disability Index (NDI), a pain diagram, the Numeric Pain Rating Scale (NPRS), and the Fear-Avoidance Beliefs Questionnaire. After the baseline evaluation, the subjects were randomly assigned to receive either thoracic spine thrust or nonthrust mobilization/manipulation. The subjects were reexamined 2 to 4 days after the initial examination, and they again completed the NDI and the NPRS, as well as the Global Rating of Change (GROC) Scale. The primary aim was examined with a 2-way repeated-measures analysis of variance (ANOVA), with intervention group (thrust versus nonthrust mobilization/manipulation) as the between-subjects variable and time (baseline and 48 hours) as the within-subject variable. Separate ANOVAs were performed for each dependent variable: disability (NDI) and pain (NPRS). For each ANOVA, the hypothesis of interest was the 2-way group x time interaction. Results Sixty patients with a mean age of 43.3 years (SD=12.7) (55% female) satisfied the eligibility criteria and agreed to participate in the study. Subjects who received thrust mobilization/manipulation experienced greater reductions in disability, with a between-group difference of 10% (95% confidence interval [CI] =5.3-14.7), and in pain, with a between-group difference of 2.0 (95% CI=1.4-2.7). Subjects in the thrust mobilization/manipulation group exhibited significantly higher scores on the GROC Scale at the time of follow-up. No differences in the frequencies, durations, and types of side effects existed between the groups. Discussion and Conclusion The results suggest that thoracic spine thrust mobilization/manipulation results in significantly greater short-term reductions in pain and disability than does thoracic nonthrust mobilization/manipulation in people with neck pain. [ABSTRACT FROM AUTHOR]

Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia. [ABSTRACT FROM AUTHOR]

Background and Purpose To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with neck pain who are likely to benefit from thoracic spine thrust manipulation. The purpose of this study was to develop a clinical prediction rule (CPR) to identify, patients with neck pain who are likely to experience early success from thoracic spine thrust manipulation. Subjects This was a prospective, cohort study of patients with mechanical neck pain who were referred for physical therapy. Methods Subjects underwent a standardized examination and then a series of thoracic spine thrust manipulation techniques. They were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. Results Data for 78 subjects were included in the data analysis, of which 42 had a successful outcome. A CPR with 6 variables was identified. If 3 of the 6 variables (positive likelihood ratio = 5.5) were present, the chance of experiencing a successful outcome improved from 54% to 86%. Discussion and Conclusion The CPR provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule. [ABSTRACT FROM AUTHOR]

Recent trends in the use of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia have been observed. However, only short-term preliminary evidence exists to support the use of these techniques. This pilot clinical trial describes the outcomes of patients with lateral epicondylalgia undergoing local treatment (LT) solely directed at the elbow and a program consisting of local treatment plus manual therapy aimed at the cervicothoracic spine (LT + MTCT). Ten consecutive patients referred to physical therapy by their primary care physician with a diagnosis of lateral epicondylalgia were randomly assigned to receive LT or LT + MTCT. Both groups received 10 treatments over a 6-week period. Outcome measures, including the Numeric Pain Rating Scale; pain-free grip strength; Disability of the Arm, Shoulder, and Hand questionnaire: and a global rating of change were completed at discharge and at 6-month follow-up. Patients in both groups exhibited clinically meaningful improvement at discharge and at the 6-month follow-up. The LT + MTCT group demonstrated greater improvement in all outcome measures as compared to the LT group. The results suggest that the incorporation of manual therapy directed at the cervicothoracic spine may be an effective adjunct to treatment directed solely at the elbow for patients with lateral epicondylalgia. [ABSTRACT FROM AUTHOR]

Peripartum posterior pelvic pain is a clinical enigma commonly encountered by physical therapists. It is hypothesized that the release of relaxin hormone during pregnancy may result in ligament laxity, which could lead to sacroiliac instability resulting in pain and decreased function. The purpose of these case reports was to describe the effects of manual physical therapy and therapeutic exercise on a peripartum patient with reports of posterior pelvic pain. Two patients referred to physical therapy by their obstetrician during their pregnancy were recruited for these case reports. During the initial examination, both patients completed a number of self-report measures including the Oswestry Disability Index, a body diagram, and the Numeric Pain Rating Scale. Both patients were treated with muscle energy techniques directed at pelvic and sacral positional faults and therapeutic exercise consisting of transverse abdominis and multifidus neuromuscular re-education; isometric hip abduction and external rotation; and a force closure sacroiliac stabilization program directed at neuromuscular re-education of the anterior and posterior oblique sling systems (hip adductors- contralateral obliques and gluteus maximus-contralateral latissimus dorsi combinations). At the time of discharge, both patients again completed the self-report outcome measures as well as a global rating of change. Both patients demonstrated a clinically meaningful improvement in their pain levels as well as perceived disability. In addition, both rated their global rating of change as "a great deal better." These case reports provide preliminary evidence suggesting that manual physical therapy and therapeutic exercise may be an effective intervention strategy for peripartum patients reporting posterior pelvic pain. [ABSTRACT FROM AUTHOR]

Lower trapezius muscle-strength deficits are a common clinical finding in patients presenting with poor postural habits. It has been speculated that zygapophyseal extension restrictions in the middle to lower thoracic spine are associated with these muscle-strength deficits. This may be a direct result of muscle inhibition related to reflexogenic influences from dysfunctional joints. The purpose of this study was to investigate the effects of manipulation applied to the lower thoracic spine (T6-T12) of asymptomatic individuals on lower trapezius muscle strength. A convenience sample of 40 subjects was randomly split into control and experimental groups of equal size. Pre-test and post-test measurements of isometric lower trapezius muscle strength were collected using a Nicholas Manual Muscle Tester. Both groups received identical assessment procedures. The experimental group received thoracic manipulations while the control group received a placebo technique. An independent group t-test was used to compare the mean change in lower trapezius muscle strength between the groups. Results revealed a significantly greater (p < 0.025) percentage increase in lower trapezius strength in the manipulation group (14%) as compared to the controls (3%). The results suggest that lower thoracic manipulation techniques may be beneficial in reducing the lower trapezius muscle inhibition commonly associated with many postural syndromes. [ABSTRACT FROM AUTHOR]

The clinical attributes that distinguish expert from novice clinicians have become a topic of great interest. To date, the majority of the literature has investigated the differences that exist in the clinical reasoning process. Despite the reported importance of joint mobilization techniques in orthopaedic practice, many of these studies have admittedly omitted the movement component (manual skills) of clinical practice from their analysis. The purpose of this study was to investigate the differences, in peripheral sympathetic nervous system activity elicited with thoracic mobilizations, between an expert and novice clinician. The expert and a novice clinician performed central grade III mobilizations to T12 on a convenience sample of 15 asymptomatic subjects utilising a crossover design. Skin conductivity was utilised as a measure of peripheral sympathetic nervous system activity. A paired samples t-test was used to compare the mean change in skin conductivity between groups. Results demonstrated that the expert clinician elicited a statistically significant (P < 0.025) greater increase in skin conductivity when compared to the novice. Although it cannot be stated with absolute certainty that expert clinicians produce a greater sympathetic nervous system response when performing spinal manipulative therapy, we speculate that differences exist between therapists, which may have clinically significant implications. [ABSTRACT FROM AUTHOR]